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1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Episiotomy
5) Making the new Way
6) E-News Readers Speak Up
7) Check It Out!
8) Question of the Week
9) Question of the Week Responses
10) For Coming E-News Themes
11) Switchboard

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1) Quote of the Week:

"In a branch of medicine rife with paradoxes, contradictions, inconsistencies, and illogic, episiotomy crowns them all. The major argument for episiotomy is that it protects the perineum from injury, a protection accomplished by slicing through perineal skin, connective, tissue, and muscle."

- Henci Goer

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2) The Art of Midwifery

I learned at a Midwifery Today conference tricks of the
trade circle to increase the room temperature as moms crown.
The moms I attend don't chill anymore and I haven't had a
baby temperature below 98 degrees since I started using this
technique. Once mom is warm enough, the thermostat is
lowered gradually. The room is toasty warm for weighing and
bathing after the baby has nursed. I tell the family in
advance that I'll be turning up the heat, and so far I've
never had a family member complain (or faint!).

Pregnant African American women with maternal hypertension
have a three-fold greater risk for postpartum hemorrhage
than those without hypertension, according to a Morehouse
School of Medicine study. The study found no significant
association between maternal hypertension and postpartum
hemorrhage among other ethnicities. According to the study,
the higher incidence of maternal hypertension among African
American women may contribute to the gap in low birth
weight, preterm deliveries, and Perinatal and infant illness
and mortality between African Americans and other U.S.
women.

- Women's Health Weekly, April 1996

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4) Episiotomy

Is the fact that midwives cut far fewer episiotomies than
doctors important? Scientific evidence shows that having an
episiotomy means more bleeding, more pain, more permanent
deformity of the vagina, more painful sexual intercourse for
months or even years. As well, unnecessary episiotomy is a
form of sexual abuse. Some women's groups in America are
rightly concerned about the practice of female genital
mutilation in parts of Africa. They need to be equally
concerned about the millions of American women who have
suffered female genital mutilation--unnecessary cutting of the genitals at birth at the hands of doctors.

While midwives trust women's bodies, use low tech assistance
such as the skilled use of their hands, and understand the
importance of preserving normalcy, doctors in general do not
trust women but trust drugs and machines, use high tech
assistance and focus on the pursuit of abnormality. So
having a highly trained surgeon obstetrician assist at your
birth is about as sensible as hiring a pediatric surgeon as
a baby sitter for your healthy two year old when you go out
in the evening. Like the obstetric surgeon who gives the
normal woman a shot to hurry her labor, the pediatric
surgeon babysitting your normal child will focus on medical
management: When your robust two year old gets tired and
fussy, the pediatric surgeon will give him or her a shot to
hurry the child to sleep. The result? In the one case the
medicalization of birth (remember, birth is not an illness)
with a lot of unnecessary risky interventions and very
expensive medical care, and in the other case the
medicalization of childhood (being two years old is also not
an illness) with unnecessary risky interventions and very
expensive babysitting. When deciding on your primary
maternity care provider, it is important to ask midwives or
doctors about their practices: find out if they prefer to
put you on your back during birth, how often they do
episiotomy, forceps or vacuum extraction, and cesarean
section. If they don't know their rates of surgical
interventions or refuse to tell you what their rates are,
look out! Beware of any tendency to patronize you, to
suggest that you cannot possibly understand all this
technical stuff, or that you should just "trust me, I'm the
doctor." -Marsden Wagner, MD, Technology in Birth

Where fears remain to obstruct the natural course of birth,
there will remain a ubiquitous use of technology.
Choices--no matter how educated or informed the consent--are
not real choices when they are made within the context of
fear. When a mother embraces a procedure along with its
dangers, we are bound by our relationship to her to make
sure the freedom of her choice is not compromised by
anxiety. In protecting the integrity of her choice in birth,
we find we exponentially affect the quality of birthing in
general: Mothers who have fears also hand down fearful
attitudes about birth to daughters, and to every other woman
who will listen. But each woman who gains the confidence to
birth as unhindered or as freely as her biological
circumstances will allow, will go on to encourage her
sisters and daughters with birth words and images that
resound with all the potential strength and beauty of birth.
And so, with-women, we must make the new way our
way--better, one birth at a time. -Jan Tritten, Making the New Way

Women who have previously had clitorotomies [episiotomies]
should be warned that they will feel considerably more
stretching and burning when no clitorotomy is performed.
During pushing, unprepared women are often alarmed by these
sensations, insisting that something is wrong. Explain the
benefits of an intact birth and what to expect. Prenatal
stretching will help them immensely. -Anne Frye,
Holistic Midwifery Vol. 1, Labrys Press, 1995

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6) E-News Readers Speak Up

Is the fact that midwives cut far fewer episiotomies than doctors important?

It is up to the mother who is cut.

- D.B.

====

The reason midwives "cut far fewer episiotomies" is because
most of us are patient and appreciate the physiology of
normal delivery. Doctors are so often only involved in the
abnormal; they do not wait for the perineum to stretch and
ease. Indeed many doctors have seldom been involved in a
normal, physiological labour.

My wife just gave birth to a 10 lb. 1 oz. baby boy on June
15. According to her doctor, the baby was six days late.
Currently our baby is suffering from meconium aspiration
syndrome. My wife had an emergency c-section; however, our
boy had already taken the meconium into his lungs. He is
being given oxygen through a ventilator and appears to be
having a difficult time at the moment breathing on his own.
The hospital where he is being taken care of seems to be
doing all they can do. It appears the levels he has are
relatively rare from the few articles I have found.

My questions are:

* What are the percentages of babies that get this type of syndrome?
* What are my baby's chances of surviving without any lung damage?
* What are the survival rates?

I know the last question sounds awful but we would like to know.
Please help. If there are any books to read on this please, let me know their names.

Q: My friend suffered from pain caused by "pubis symphasis"
during her past five pregnancies. She is currently eight
weeks into her sixth pregnancy, and she's already
experiencing pain. Are there any exercises that can help?
Any magic cures (homeopathic remedies, etc.)? She broke her
coccyx during her first labour 16 years ago, but went on to
have normal, uncomplicated births with her fourth &
fifth children. Her youngest child will be two when the new
baby arrives. Her birth was extremely fast (40 minutes). Is
homebirth an option?

- Chamutal
UK

====

A: In osteopathic medicine, some very simple manipulations
can be used to "reset" the cartilage of the pubis symphysis.
A D.O. in your area who is skilled in osteopathic
manipulative medicine (OMM) may be able to offer some relief
(and, perhaps, teach her some muscle energy techniques to do
at home).

- Tami Michele, med. student

====

A: SPD is the new discovery in the U.K. Where I work there is one of the highest instances. Things that can help:

- Rest!
- Sleep on a slippery sleeping bag so you can turn over easily in bed
- Try not to abduct hips
- Sit on a plastic bag in the car so you can slide when getting out
- A pelvic support like a girdle reduces pain

Homebirth is no problem; just be careful about abducting the
hips. Use a piece of string to measure how far you can
comfortably open your legs. Use the string in labour so as
not to allow anyone to open your legs more than this
distance! --If the condition gets quite bad you may need
crutches. Hydrotherapy is really useful.

- Julie

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2. What do you carry in your birth bag? Anything unusual, and if so, for what purpose? (July 12 issue)

3. How do we help women in isolated communities birth with
dignity and freedom, trust themselves, and not be separated
from their families? Who in their communities will provide
midwifery services and how will they go about doing so? And
what can we do to help? Where do we start? (July 19 issue)
(Editor's note: These questions were asked by a midwife who
lives and works in the Yukon Territories. Let's help her
help her communities!)

Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

o=o=o=o=o=o

11) Switchboard

Editor's Note: If you are sometimes receiving only one part of your E-News issue and you use AOL, call their number to complain! 888-346-3704.

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With all the discussion of cervical lips and when to push, I have some questions concerning both. I apprentice in a
midwifery practice where it is standard of care to do a
vaginal exam to check for complete dilation when a woman
starts to make those pushing noises or vocalizes an urge to
push. The theory is that we are making sure that there is
no lip and that a woman is truly "complete." Frequently we
do find a lip, and usually the woman is asked to pant and
breathe through a few contractions before another vaginal
exam is done, to make sure the lip is gone before she gets
the OK to push. If the lip is swollen, then it is treated
with time, ice, different positions, homeopathy.

I am concerned that we end up directing the birth process
too much, and the woman doesn't feel trusted to know when
she should or shouldn't push. We tell women to "listen to
their bodies" and that they'll "know what to do," and then
we second-guess them, and have to make sure we know for
ourselves. How do other midwives feel about this issue? I
would love to think that if a woman's body begins pushing
naturally, then even if there was a lip, that it would just
melt away. I would also like to think that I will be more
trusting when I get to primary care, but I want to be
informed, not naive.

- Jenny
Oregon

====

I agree that in most situations it would be fine to deliver
a trisomy 18 baby at home. But there are occasions, just as
with other births, when it would not be appropriate. One of
my moms who had a trisomy 18 baby also had a placental
abruption. I sent her in for an ultrasound because of
symptoms of partial abruption. The abruption, SGA, trisomy
18 pattern of defects were all missed on the ultrasound and
they sent her home until she went into more serious
abruption. Then they sent her to a larger hospital for a
c-section. The problems for mother were more because of the
placental abruption than the trisomy 18 birth. The baby
lived about 35 hours.

- Judy Jones, CPM

====

I looked up trisomy 18 in Taber's: "causes severe deformity
and mental retardation. These children usually do not
survive beyond the first year of life. Characterized by
prominent occiput, overlapping of index finger over third
finger, frequent facial abnormalities, straight nose coming
off sharply from the forehead, low-set ears, and cleft
palate and lip."

As a midwife I don't see anything here contraindicating a
natural vaginal delivery. With cleft palates there are often
special feeding needs, but that can be worked out with a
lactation counselor who has training in that area.
Anecdotal evidence suggests that babies with severe
anomalies often present other than vertex, so discussion
about a breech birth might be in order.

The provider handbook for the AFP/Triple Screen says that
these babies often spend what little time they have in a
neonatal intensive care unit--all the more reason to have a homebirth.
Our practice has had a baby with (undiagnosed prenatally)
severe anomalies inconsistent with life. We ended up in
hospital because of maternal infection in labour (broken
waters), where a sono told us what was coming. The mom went
on to have a completely natural, uncomplicated 10 hour
labour and birth, catching her baby in the bath with only
her partner and one of us with her. It was all she had left
of her original dream and she cherishes that memory.
If your family wants a homebirth, they should have the same
opportunity as any other family, because they will have only
a short amount of time with their child; because that time
will be spent walking a path far and away from the one they
envisioned when creating this child; because this child will
be taken from the family soon enough, it should not be
"taken" from its mother's body. You and your family are in
our prayers.

- Anon.

====

My friend is an independent midwife, and the study she
mentions (below) is on the web atwww.utoronto.ca/breech. If
you can help in any way, I would appreciate it, and so would she and her
daughter.

- Jackie Mawson

Mary writes:
Today I accompanied my foster daughter to an antenatal at
KEMH. She is 33 weeks pregnant with twins, 3rd pregnancy.
First birth was difficult--forceps, 8 lb 8 oz.; second birth
was normal, 8 lb 8 oz. We have been querying the
recommendation for a c-section because the baby is breech
and because it's twins. The doctor said research previously
found the two modes of birth are equal in outcome but new
information says *definitely* c-section for all breeches
whether single or multiple, primip or multip.

Supposedly there is a multicentre research program taking
place, possibly out of Oxford, that has just been stopped
because the outcome for breeches was so bad. He was unable
to give me any other information and said the results
wouldn't be published until next year, so he couldn't help
me with my questions, such as those about maternal
morbidity.

This has upset my daughter of course--she feels devastated.
I know that she will have a c-section if it means her babies
are at risk, but she feels a little trapped. Any help with
information about this research? I don't want to give her my
intuitive response as I may be misleading her in my desire
for her to have a normal birth.

- Mary Murphy

====

I read on in disbelief when it was stated that cord knots
are not dangerous. How can they not be dangerous? The
umbilical cord is the lifeline to the baby. If that cord
tightens the baby will not receive all vital oxygenation,
nourishment, etc. I completely disagree with the person who
believes knots to be "OK." As an RN in an L&D dept. I have
seen my share of knots--some loose, OK, no problem, others
so tight that the baby in some instances was delivered
without life.

- Margie Bou, RN

====

I am a family nurse practitioner who will be working in an OB/GYN office. Can anyone direct me to a reference with protocols for the pregnant patient?

- Joanne Pecoraro

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